Heartland Virus Symptoms: Fatal Mid-Atlantic Case Raises Awareness
Heartland virus symptoms can resemble other tick-borne illnesses
Severe disease may involve neurologic symptoms and organ failure
A fatal Mid-Atlantic case highlights an emerging regional risk
By Daniel J. Cameron, MD, MPH
Heartland virus symptoms may include fever, fatigue, decreased appetite, headache, nausea, diarrhea, and muscle or joint pain. Laboratory findings can include low white blood cell counts, low platelet counts, and elevated liver enzymes.
Because these findings can resemble ehrlichiosis, anaplasmosis, and other tick-borne infections, Heartland virus disease may be difficult to recognize during its early stages. There is no widely available commercial diagnostic test, no approved antiviral treatment, and no licensed vaccine for the infection.
Investigators identified a fatal case of Heartland virus disease acquired in the Maryland or Virginia region—an area where the virus had not been widely recognized.
In their article, “Fatal Case of Heartland Virus Disease Acquired in the Mid-Atlantic Region, United States,”1 Liu and colleagues describe the case of a man in his 60s who acquired Heartland virus in either Maryland or Virginia.
What is Heartland virus?
Heartland virus is a rare tick-borne virus believed to be transmitted primarily by the Lone Star tick, Amblyomma americanum. Cases have been reported mainly in the eastern, southeastern, and south-central United States.
The illness can initially resemble bacterial infections such as ehrlichiosis or anaplasmosis. However, antibiotics do not directly treat Heartland virus because it is a viral infection.
What are the symptoms of Heartland virus?
Heartland virus symptoms generally develop within approximately two weeks after an infected tick bite, although patients often do not remember being bitten.
Reported symptoms include:
- Fever
- Severe fatigue
- Loss of appetite
- Headache
- Nausea
- Diarrhea
- Muscle aches
- Joint pain
Patients may also develop low white blood cell counts, low platelet counts, and mild to moderate elevations in liver enzymes. Severe cases can involve confusion, encephalopathy, respiratory failure, kidney failure, and other organ complications.
A patient does not need to recall a tick bite for Heartland virus disease to be considered. Lone Star ticks can be difficult to notice, and their bites may go unrecognized.
Fatal Heartland virus case in the Mid-Atlantic region
The man was admitted to the hospital in November 2021 with fever, diarrhea, shortness of breath, muscle aches, and malaise that had been ongoing for five days.
He had a history of splenectomy, hypertension, remote trauma, and coronary artery disease. He did not recall a tick bite and did not have an erythema migrans rash.
“The range of [Heartland virus] could be expanding in the United States.”
“An arboviral disease was the leading diagnostic consideration, but limited availability of commercial diagnostic testing for tickborne diseases delayed diagnosis,” Liu and colleagues wrote.
The patient was treated clinically for a possible bacterial tick-borne infection with doxycycline.
Because early ehrlichiosis and anaplasmosis can look nearly identical to Heartland virus disease, empiric doxycycline may be appropriate while clinicians evaluate for bacterial tick-borne infections. However, doxycycline does not treat Heartland virus itself.
“Two days later, on day 7 after symptom onset, the patient returned to the emergency department with confusion, an unsteady gait, and new fecal and urinary incontinence,” according to the authors.
He subsequently developed encephalopathy, low sodium, abnormal liver function tests, and worsening fatigue.
“He had acute respiratory failure, renal failure, and a cardiac arrest. He was transitioned to comfort care and died on day 13 after symptom onset,” Liu and colleagues wrote.
Heartland virus identified during autopsy
An autopsy revealed that tissue samples were positive for Heartland virus.
Heartland virus was detected in samples from the patient’s heart, accessory spleen, kidney, and liver.
The Virginia Department of Health conducted a tick drag on the man’s property and collected 193 Lone Star ticks. None of the collected ticks tested positive for Heartland virus.
Negative testing of ticks collected after the patient’s illness does not establish where or precisely when he became infected. Nevertheless, the confirmed human infection suggests that clinicians should include Heartland virus among the differential diagnoses for compatible illnesses in the Mid-Atlantic region.
Why can Heartland virus be difficult to diagnose?
Early Heartland virus symptoms overlap with those of several other tick-borne illnesses. Fever, fatigue, diarrhea, low white blood cell counts, low platelet counts, and elevated liver enzymes may also occur with ehrlichiosis or anaplasmosis.
Heartland virus should be considered when a patient has a compatible illness and potential tick exposure, particularly when laboratory abnormalities persist or the patient does not improve as expected with doxycycline.
Diagnostic testing is not commercially available in the United States. Clinicians who suspect Heartland virus disease may need to contact their state or local health department for assistance with molecular or antibody testing.
Is there a treatment for Heartland virus?
There is no specific antiviral treatment for Heartland virus disease. Management is supportive and may include intravenous fluids, medications for fever or pain, respiratory support, and treatment of organ complications.
Many patients recover with supportive care. However, severe and fatal disease has been reported, particularly among older adults and people with underlying medical conditions or impaired immune function.
Patients with a suspected tick-borne illness may still receive doxycycline while clinicians evaluate for ehrlichiosis, anaplasmosis, Rocky Mountain spotted fever, and other treatable bacterial infections.
Is there a Heartland virus vaccine?
There is currently no licensed vaccine to prevent Heartland virus disease. Prevention depends on reducing exposure to ticks, using tick repellents, wearing protective clothing, performing tick checks, and promptly removing attached ticks.
A Lyme disease vaccine, if approved in the future, would not be expected to prevent Heartland virus or other infections transmitted by ticks.
Frequently Asked Questions
What are the first symptoms of Heartland virus?
Early Heartland virus symptoms may include fever, fatigue, decreased appetite, headache, nausea, diarrhea, and muscle or joint pain. Blood tests may show low white blood cell and platelet counts and elevated liver enzymes.
How soon do Heartland virus symptoms appear?
Symptoms generally begin within approximately two weeks after an infected tick bite. However, many patients do not remember being bitten by a tick.
Can Heartland virus be fatal?
Yes. Many patients recover with supportive care, but severe and fatal cases have been reported. Older adults and people with underlying medical conditions or impaired immune function may be at greater risk for serious complications.
What is the Heartland virus mortality rate?
Heartland virus disease remains rare, so the precise mortality rate is uncertain. Fatal infections have been reported, particularly among older adults and patients with underlying medical conditions.
How common is Heartland virus?
Heartland virus disease is rare compared with Lyme disease, ehrlichiosis, or anaplasmosis. Additional cases may be recognized as clinician awareness and access to diagnostic testing improve.
Which tick carries Heartland virus?
Human case reports and laboratory studies indicate that Heartland virus is transmitted primarily by the Lone Star tick, Amblyomma americanum.
Does doxycycline treat Heartland virus?
No. Doxycycline does not directly treat Heartland virus because it is a viral infection. It may be prescribed while clinicians evaluate for bacterial tick-borne diseases such as ehrlichiosis or anaplasmosis, which can produce similar symptoms.
Is there a vaccine for Heartland virus?
No licensed vaccine is currently available for Heartland virus. Prevention focuses on avoiding tick bites and promptly finding and removing attached ticks.
Can someone have Heartland virus without remembering a tick bite?
Yes. A person may not notice or remember a tick bite. A known tick bite is therefore not required for clinicians to consider Heartland virus in a patient with compatible symptoms and possible tick exposure.
Clinical Takeaway
Heartland virus disease can resemble ehrlichiosis, anaplasmosis, and other tick-borne infections during its early stages. The absence of a remembered tick bite does not exclude the diagnosis, and limited access to testing may delay confirmation.
The fatal case acquired in Maryland or Virginia suggests that Heartland virus may be present outside areas where it has traditionally been recognized.
Heartland virus should remain in the differential diagnosis when patients present with compatible symptoms, low blood cell counts, elevated liver enzymes, and potential Lone Star tick exposure, particularly if they fail to improve as expected.
Related Articles
Learn more about emerging tick-borne viruses and illnesses that can resemble bacterial tick-borne infections:
10 Cases of Heartland Virus Reviewed
What Is Powassan Virus?
Can Powassan Virus Cause Encephalitis?
References
- Liu S, Kannan S, Meeks M, et al. Fatal Case of Heartland Virus Disease Acquired in the Mid-Atlantic Region, United States. Emerg Infect Dis. 2023;29(5). doi:10.3201/eid2905.221488.
- Centers for Disease Control and Prevention. Diseases Transmitted by Ticks. Last accessed February 26, 2023.
- Centers for Disease Control and Prevention. Symptoms, Diagnosis, and Treatment: Heartland Virus. Updated November 19, 2025.
Dr. Daniel Cameron, MD, MPH
Lyme disease clinician with over 30 years of experience and past president of ILADS.
Symptoms • Testing • Coinfections • Recovery • Pediatric • Prevention
